Approximately 7-14% of older adults living independently in the community, including more than 5% of those who have never fallen, experience moderate to severe fear of falling (FF) and avoid multiple activities as a result. At least 3% avoid leaving their homes or yards due to fear. Excessive FF leads to decreased physical activity, disability, loss of independence, depression, anxiety, reduced social engagement, and poor quality of life. It is also a major independent risk factor for falls. Interventions targeting FF, typically delivered in groups and incorporating cognitive restructuring, education, and exercise, increase fall-related self-efficacy. Avoidance is resistant to treatment, however, and almost 40% of patients enrolled in these interventions drop out. Factors associated with attrition include high levels of FF, indicating that the individuals most in need of such programs are those most likely to withdraw prematurely. These data suggest that avoidance should be targeted in treatment, and that interventions should be designed to reach those with severe fear and avoidance who are most likely to drop out of traditional FF programs. Yet despite the similarities between FF and anxiety disorders, and the fact that the most effective behavioral treatment for most anxiety disorders is exposure therapy, no FF interventions to date have incorporated an exposure component. Overall, the existing research suggests the need for an intervention that combines exposure therapy with other elements that have proven effective for reducing FF. Such an intervention must also be sensitive to issues of patient safety. The proposed project aims to develop an in-home, physical therapist-delivered intervention, Activity, Balance, Learning, and Exposure (ABLE), that integrates exposure therapy and cognitive restructuring with exercise, education about fall risks, a home safety evaluation, and a medication review for older adults with excessive and disabling FF. After developing and pilot testing this new intervention with 20 older adults with FF, we propose to conduct a feasibility study in which 40 patients are randomly assigned to ABLE or an education control condition. By developing and testing a new intervention to address a prevalent geriatric anxiety condition with potentially devastating public health consequences, this line of research has the promise to fill a major gap in knowledge and clinical practice. PUBLIC HEALTH RELEVANCE: Excessive fear of falling (FF) leads to decreased physical activity, disability, loss of independence, depression, anxiety, reduced social engagement, poor quality of life, and increased fall risk in older adults. Yet despite the similarities between FF and anxiety disorders, and the fact that the most effective behavioral treatment for most anxiety disorders is exposure therapy, no FF interventions to date have incorporated an exposure component. This R34 application proposes to develop an in-home, physical therapist-delivered intervention integrating exposure therapy and cognitive restructuring with exercise, education about fall risks, a home safety evaluation, and a medication review for older adults with excessive and disabling fear of falling.